Medical Director - Outpatient Medicare

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The Medical Director relies on medical background and reviews health claims. The Medical Director work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.
The Medical Director actively uses their medical background, experience, and judgement to make determinations whether requested services, requested level of care, and/or requested site of service should be authorized. All work occurs with a context of regulatory compliance, and work is assisted by diverse resources which may include national clinical guidelines, CMS policies and determinations, clinical reference materials, internal teaching conferences, and other sources of expertise. Medical Directors will learn Medicare and Medicare Advantage requirements and will understand how to operationalize this knowledge in their daily work.

The Medical Director’s work includes computer-based review of moderately complex to complex clinical scenarios, review of all submitted clinical records, prioritization of daily work, communication of decisions to internal associates, and possible participation in care management. The clinical scenarios predominantly arise from inpatient or post-acute care environments. Has discussions with external physicians by phone to gather additional clinical information or discuss determinations regularly, and in some instances, these may require conflict resolution skills. Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within their scope.

The Medical Director may speak with contracted external physicians, physician groups, facilities, or community groups to support regional market priorities, which may include an understanding of Humana processes, as well as a focus on collaborative business relationships, value-based care, population health, or disease or care management.

Use your skills to make an impact

Responsibilities

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Review health claims and clinical documentation to evaluate moderately complex to complex cases requiring medical judgment and in-depth analysis.

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Determine medical necessity and make authorization decisions regarding requested services, level of care, and site of service.

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Conduct computer-based reviews of clinical scenarios, primarily involving inpatient and post-acute care settings.

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Assess submitted medical records against national clinical guidelines, CMS policies and determinations, clinical reference materials, and internal policies.

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Apply Medicare and Medicare Advantage requirements accurately and operationalize this knowledge in daily utilization management decisions.

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Prioritize daily case reviews and ensure timely, accurate communication of determinations to internal associates and stakeholders.

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Engage in peer-to-peer discussions with external physicians to obtain additional clinical information, clarify treatment plans, and discuss authorization decisions.

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Use professional judgment and conflict resolution skills when handling complex or disputed clinical determinations.

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Provide medical interpretation to confirm whether services delivered by healthcare professionals align with clinical standards, regulatory requirements, Humana policies, and applicable contracts.

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Support grievance and appeals reviews, and in some roles, contribute oversight related to coding practices, clinical documentation, outpatient services, and durable medical equipment.

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Collaborate with care management, cross-functional teams, regional leadership, and other Humana departments to support compliance, consistency, and business priorities.

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Build and maintain productive relationships with contracted physicians, physician groups, facilities, and community partners in support of value-based care, population health, and regional market initiatives.

Required Qualificat